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Medicaid & CHIP

Medicaid

Medicaid is a state-administered health insurance program for certain individuals and families with low incomes and resources. Each state sets its own eligibility requirements for their program subject to federal rules.

Prior to passage of the Affordable Care Act (ACA), adults without dependent children were generally excluded from Medicaid coverage. Now states have the option to extend eligibility to low income adults under age 65 with incomes up to 138 percent of the poverty level (approximately $16,394 for an individual and $33,534 for a family of four in 2016), including those without dependent children. Over half of states have expanded their Medicaid eligibility.

Benefits Covered

States also have flexibility in determining which benefits are covered under Medicaid; however certain benefits are required by federal rules.

Required benefits include:

inpatient and outpatient hospital services

doctor's office visits

laboratory and X-ray services

long-term-care services, such as nursing home care or community-based care.

States have the option to include additional services, and many do. For example, podiatrist services are optional, but only seven states do not cover it under their Medicaid programs. The cost of health care for people in Medicaid varies by state but is extremely limited for most.

How to Learn More and to Apply

Each state's Medicaid program covers different benefits, and has different rules for eligibility. As a result of the ACA, many states calculate income to determine eligibility in a different way than they did before 2014 and some states offer Medicaid to more people now. So, if someone was previously determined ineligible for Medicaid, he or she should consider reapplying.

The Health Insurance Marketplace in each state offers a single application to determine whether a person is eligible for Medicaid or eligible for help purchasing private health insurance through the Marketplace. For more information on the Health Insurance Marketplaces, visit www.healthcare.gov or call 1-800-318-2596. See our fact sheet on the Health Insurance Marketplaces at www.diabetes.org/HealthInsuranceMarketplaces.

Children's Health Insurance Program

The Children's Health Insurance Program (CHIP) is a state-administered health insurance program for children up to age 19 in low- and moderate-income families with incomes too high to qualify for Medicaid. Some states also cover pregnant women and parents under CHIP.

Benefits Covered

Since states have flexibility to design their own CHIP program within Federal guidelines, benefits vary by state and by the type of CHIP program. Most CHIP programs must include coverage for Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services, as well as inpatient and outpatient hospital services, doctor's office visits, dental services, and laboratory and x-ray services.

States can choose to impose limited enrollment fees, premiums, deductibles, coinsurance, and copayments for children and pregnant women enrolled in CHIP, generally limited to 5% of a family's annual income. Cost sharing is prohibited for some services, like well-baby and well-child visits.

How to Learn More and to Apply

You can learn more about the CHIP program in your state by visiting www.insurekidsnow.gov, or by calling 1-877-543-7669.

The Health Insurance Marketplace in each state offers a single application to determine whether a person is eligible for Medicaid or for help purchasing private health insurance through the Marketplace. Through the Marketplace application process you will also be notified if it looks like anyone in your household is eligible for CHIP.